Intake Forms

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Intake Type

Child's Name*

First Last

Nickname

Birth Date:*

MM slash DD slash YYYY

Sex

Male

Female

Address*

Street Address City State ZIP Code

Child's Primary Language

Other Languages Spoken

Siblings (names/ages)

With whom does child live most of the time?*

Biological Mother

Biological Father

Step Mother

Step Father

Adoptive Mother

Adoptive Father

Grandparents

Other

With whom does child live most of the time? (please specify)*

Does another parent or legal guardian share legal custody or medical decision-making authority for this child?*

No, I am the sole legal decision-maker

Yes, joint legal custody / shared decision-making authority

Other (please specify)

Legal custody or medical decision-making information:*

Please briefly describe the arrangement (e.g., joint legal custody per court order, informal co-parenting agreement).

Name*

First Last

Email*

Mobile Phone*

SMS Appointment Reminders

Yes

Name